EMPLOYMENT APPLICATION FOR TAYLOR …

1 EMPLOYMENT APPLICATION FOR TAYLOR county community supervision AND CORRECTIONS department We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, veteran status, or any other legally protected status. If you require accommodation of a disability in order to complete any portion of the APPLICATION process, please inform Ms. Jessica Tipton at 674-1247. So that we can have the best opportunity to provide necessary and reasonable accommodation, we ask that you give us a much notice as possible prior to the need. (PLEASE PRINT) Position Applied For: Date of APPLICATION : How Did You Learn About This Position? Advertisement Friend Walk-In Other:_____ EMPLOYMENT Agency Relative CSCD Website Last Name First Name Middle Name Street Address City State Zip Telephone Number (s) Home: Work: Cell: Email Address: Social Security Number: Have you ever filed an APPLICATION with us?

2 YES NO If yes, when:_____ Have you ever interviewed with this department ? YES NO If yes, when:_____ Have you ever been employed with this department ? YES NO If yes, when:_____ Do you have any relatives employed by this department or TAYLOR county ? YES NO If Yes, Name:_____Dept:_____Relationship:_____ Are you currently employed? YES NO May we contact your current employer to verify this? YES NO N/A Are you legally authorized to work in the United State? YES NO Proof of citizenship or immigration status will be required upon EMPLOYMENT . On what date would you be available for work? _____ Are you available to work? Full Time Part Time Shift Work Temporary Are you currently on lay-off status and subject to recall? YES NO Can you travel if a job requires it? YES NO Have you ever been convicted, received deferred adjudication, or YES NO placed on pre-trial supervision for a misdemeanor or felony offense?

3 If Yes, please explain:_____ PLEASE NOTE: A record does not constitute an automatic bar to EMPLOYMENT ; however, failure to disclose your criminal history will result in the disqualification of your APPLICATION . EDUCATION Name, City and State of School Course of Study Years Completed Diploma Degree High School Graduate YES NO Undergraduate College Graduate YES NO Graduate Professional Graduate YES NO Other (Specify) Graduate YES NO Indicate any foreign languages you can speak, read and/or write. Fluent Good Fair Speak Read Write Describe any specialized training, apprenticeship, skills and extra-curricular activities. Describe any job-related training received in the United States military. EMPLOYMENT EXPERIENCE Start with your present or last job. Include all jobs and account for all gaps in EMPLOYMENT or at least for the last ten years. Employer Dates Employed From To Work Performed Address Telephone Number(s) City and State Hourly Rate / Salary Starting Final Job Title Reason for Leaving Supervisor s Name Employer Dates Employed From To Work Performed Address Telephone Number(s) City and State Hourly Rate / Salary Starting Final Job Title Reason for Leaving Supervisor s Name Employer Dates Employed From To Work Performed Address Telephone Number(s) City and State Hourly Rate / Salary Starting Final Job Title Reason for Leaving Supervisor s Name EMPLOYMENT EXPERIENCE cont.

4 Employer Dates Employed From To Work Performed Address Telephone Number(s) City and State Hourly Rate / Salary Starting Final Job Title Reason for Leaving Supervisor s Name Employer Dates Employed From To Work Performed Address Telephone Number(s) City and State Hourly Rate / Salary Starting Final Job Title Reason for Leaving Supervisor s Name If you need additional space, please continue on a separate sheet of paper. Have you ever been discharged or requested to resign from any position? YES NO If yes, give details: _____ _____ _____ List professional, trade, business or civic activities and offices held. You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status: ADDITIONAL INFORMATION Other Qualifications: Summarize special job-related skills and qualifications acquired from EMPLOYMENT or other experience.

5 Specialized Skills: Please check applicable skills/equipment operated ___ Microsoft Office ___ Fax Other (list) ___ Windows Operating System ___ PC _____ ___ Internet Explorer ___ Multi-line phone system _____ ___ Computer Skills ___ Calculator/10-key _____ State any additional information you feel may be helpful to us in considering your APPLICATION . Note to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING. Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied? ____ YES ____ NO Personal References (not relatives or former employers) Name: _____ Home: ( )_____ Cell: ( )_____ Employer Name: _____Employer: ( )_____ Name: _____ Home: ( )_____ Cell: ( )_____ Employer Name: _____Employer: ( )_____ Name: _____ Home: ( )_____ Cell: ( )_____ Employer Name: _____Employer: ( )_____ Name: _____ Home: ( )_____ Cell: ( )_____ Employer Name: _____Employer: ( )_____ APPLICANT S STATEMENT I certify that answers given herein are true and complete to the best of my knowledge.

6 I authorize investigation of all statements contained in this APPLICATION for EMPLOYMENT as may be necessary in arriving at an EMPLOYMENT decision. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any EMPLOYMENT relationship with this organization is of an at will nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this at will EMPLOYMENT relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. I understand also that false, misleading or incomplete information given in my APPLICATION or interview(s) may result in the termination of my candidacy for EMPLOYMENT , or, in the event of EMPLOYMENT , may result in discharge. I understand that I am required to abide by all rules and regulations of TAYLOR county , as set by the department .

7 WITHOUT SIGNATURE, APPLICATION WILL BE REJECTED: _____ _____ Signature of Applicant Date FOR PERSONNEL department USE ONLY Arrange Interview Yes __ No __ Remarks: _____ Employed Yes ___ No ___ Date Employed _____ Job Title _____ Hourly Rate/Salary _____ department _____ By _____ Name and Title Date Notes: (To include any verbal information given) _____